Saturday, October 5, 2013

Corporate Drug Pushers and Their Blame-Avoidance Techniques

I’m in the process of reading Deadly
Medicines and Organized Crime: How Big Pharma Has Corrupted Healthcare, by
the Danish trials expert, physician, and epidemiologist, Peter C. Gøtzsche. I
hope soon to have a book report for this blog. In the meantime I am going to
comment on a New York Times article
that Dr. Gøtzsche cites and that I apparently missed first time around back in
2006:

Brief background: In early days pharmaceutical firms got insulin from
pig and beef pancreas from slaughterhouses; that led to some problems with
allergies. The next big advance was the ability to synthetically manufacture
human insulin, which ended those problems. However, not content to stop there,
various folks kept tinkering with insulin and came up with supposedly new and
improved bioengineered forms, which are questionably better than plain human
insulin, but of course are much more expensive. Gardiner Harris and Robert Pear
summarized for the Times how Eli
Lilly had at first cornered most of the U.S. insulin market, but that recently
the Danish-based firm Novo Nordisk was trying hard to capture a good chunk of
the market for its own products. In 2006 an investigation was going on to see
if Novo Nordisk had crossed any legal lines in pushing their products.

The revelations Harris and Pear recounted (based on internal company
documents they obtained) included how Novo Nordisk reps had paid “anchors” in doctors’
offices, usually nurses or medical assistants, to be on the lookout for
patients taking insulin who could be switched to the Novo product, paying them
on the basis of how many prescription switches they achieved—while all the
while claiming that these folks were simply being paid to “educate” patients
about diabetes. Novo also contracted
with the Rite Aid pharmacy chain to give them special discounts on their drugs
in exchange for help switching patients in their database to Novo insulin, and
were found to have paid at least one Rite-Aid pharmacist what seems to be a
kickback for patients who were switched.

What I most want to focus on here are two documents unearthed in the Times article. The first was a memo that
Vikki Tolbert, a Novo district manager, sent to her staff of sales reps in
March 2004:

“Our goal is 50 or more
scripts [switched] per week for each territory….If you are not achieving this
goal, ask yourself if those doctors that you have such great relationships with
are being fair to you. Hold them accountable for all the time, samples,
lunches, dinners, programs and past preceptorships that you have provided or
paid for and get the business!! You can do it!!”

This memo is great because it’s a laundry list of all the forms of
bribes that reps pay to docs, and that when either the reps or the docs are
challenged about them, insist that all these things are not bribes at all, but
rather education, or else have some other fully legitimate purpose, and the
last thing on the reps’ minds is that the docs are in any way beholden to them
as a result of taking these things. Here
is as blatant a statement as I have ever seen that yes, it’s a bribe, pure and
simple; if the docs take the money, they owe the rep the business in return.

So now we turn to Rite Aid. The corporation sent a letter to its
pharmacists in February 2005, saying, “Each Novo Nordisk product we dispense
brings us 20 to 40 percent better profit margin,” adding that these
sales add millions of dollars to the corporation’s “bottom line.”

So what did Rite Aid have to say when told that one of its pharmacists
was being paid by Novo to switch patients to their drugs? Well, of course they
were shocked and had no idea that such a thing was going on.

Now, let’s back up a step. Last I heard, Rite Aid was a pharmacy chain,
not a medical practice. I agree that pharmacists know a lot about drugs and it
would be nice if physicians listened more to the advice that pharmacists could
give them—as long as that advice was genuinely the pharmacists’ and not bought
and paid for by the drug company. But bottom line is that doctors are supposed
to prescribe drugs and the pharmacy is supposed to fill then script with the
right drug, and help educate the patient about how to take it. If the doc has
made a major error, such as prescribing Drug B to a patient already on Drug A
where there’s a dangerous interaction between A and B, the pharmacist should
call the physician immediately and warn of the problem—but that’s a far cry
from switching equivalent drugs because Rite Aid makes a handsome bundle.

So the corporation is here sending a memo to pharmacists which is
highly improper because it suggests a line of action that is quite contrary to
the role of the pharmacy—but the company is simultaneously covering its own
rear, so that if any pharmacist actually decides to cash in on this deal, and
ask for an extra bonus from Novo for doing the switching, then the company can
say it was all the fault of that one renegade pharmacist and had nothing at all
to do with company policy.

Dr. Gøtzsche, in his intemperately titled book, more
or less concludes that Big Pharma and everyone who’s in bed with them will say
various things about their activities—and we cannot believe a single word of it
because they routinely lie through their teeth. Maybe that’s a bit far even for
a pharmascold like me to go—more on that when I get to the book review post—but from
this particular set of examples, you can see where he’d get such an idea.